Tucker Park Crossing Of Journey Llc

could not open or figure out how to open the gate, which was the only way off of the porch. He further

was going to the street to check for the resident. He ran to the street by the road while looking both

houses down from the house that you see when you look directly out of the door [from the facility].

Once he saw her, he ran down towards R62 to make sure she was safe. R62 was not willing to walk back so he stayed in place until assistance arrived. He was not able to look at the time. He revealed she was not upset but she was not wanting to come back to the facility. He stated she came back to the facility and was still attempting to get out again [later that day] which was normal.

Stated the doors had not been locked when he made it back to the facility around 10:15-10:30 AM and was instructed to stand by the doors but could not remember who told him to do that but the Unit Manager and the DON were present on the hall.

When asked about the resident, he stated she exit sought daily and constantly was going to the doors shaking on them. He further stated her bags were always packed and at the door.

Interview on 01/30/2026 at 2:38 PM with the DON revealed the sprinkler system was being serviced and was not supposed to trip the electrical system [power].

Stated the care plan was updated that same day to include a wanderguard since R62 did not have an elopement prior to 12/30/2026.

Interview on 01/30/2026 at 5:47 PM with the Administrator revealed he was not onsite from when he received the call of the elopement, the staff had already noticed that R62 was gone, and they had gone out and received the message they had located her outside. At that time, apparently the sprinkler guys were there, and all the doors were open and they [all staff] had started fire watch on the doors.

The Maintenance Assistant was put on the line/phone and once the sprinkler technician realized the problem (when the facility called the code), another supervisor from the sprinkler company did the test wrong, which had never happened before.

115561 01/30/2026

Tucker Park Crossing of Journey LLC 4608 Lawrenceville Highway Tucker, GA 30084

Review of the MAR indicated documentation that the patch was administered on [DATE] at 10:54 AM, [DATE] at 10:26 PM, and [DATE] at 10:13 AM, suggesting no doses were missed.

The Unit Manager met with LPN BB to address documentation reflecting administration when no patch was available. LPN BB stated she did not know how the documentation occurred and was instructed to correct the entry.

Follow-up interview on [DATE] at 11:24 AM revealed RN AA contacted the evening nurse who stated she administered the patch the previous evening but did not realize she clicked on that.Interview on [DATE] at 3:05 PM with R113 revealed that she did not receive her Lidocaine patch at all the previous day and had not received one yet on the day of the interview.

She reported requesting Tylenol for pain management until her Lidocaine patch became available.Interview on [DATE] at 12:52 PM, via telephone with Name of company Pharmacy revealed that the pharmacy representative confirmed receipt of a new order that day for a Lidocaine 4% patch for R113.

She stated the previous order had expired on [DATE], which prevented processing a refill.Interview on [DATE] at 1:11 PM with RN CC stated that she was unfamiliar with the procedure for priming an insulin pen or holding the pen in place after it reached zero/clicks.

She indicated she had not received training or been made aware of any facility policy regarding insulin pen administration. RN CC further explained that she did not administer the resident's morning insulin as ordered because the resident was not in his room at the scheduled time.

She believed that since the insulin was long-acting, the timing would not adversely affect the resident.Interview on [DATE] at 9:46 AM with LPN BB stated that when reviewing R114's metoprolol order, she only considered the heart rate parameter and did not account for the blood pressure.

She acknowledged that administering the medication outside the prescribed parameters, particularly with a low blood pressure, could cause dizziness or confusion.

The LPN stated she would monitor the resident's blood pressure and watch for side effects, and if the BP fell below 100 mmHg, she would contact the NP for possible intervention.Interview on [DATE] at 9:45 AM with the Director of Nursing (DON) revealed that nurses were required to verify the MAR at least three times to ensure accuracy and prevent medications errors.

She further emphasized that the facility's expectation was a zero-error rate for all medication administration.

Nurses must never document a medication as given if it was not available. If a medication was unavailable in the cart or automated medication system, the nurse was expected to contact the pharmacy to obtain the medication, notify the physician of the missed dose, inform the responsible party, and document all actions taken in the MAR.

For insulin pens, nurses must prime with 2 units and hold the pen in place for five seconds to ensure proper delivery, as failing to do so may result in administering air and improper absorption. If a medication was given outside the physician's parameters, nurses were expected to assess the resident, monitor blood pressure, notify the physician, and document all actions, since deviations could result in the resident's blood pressure dropping dangerously low.

115561 01/30/2026

Tucker Park Crossing of Journey LLC 4608 Lawrenceville Highway Tucker, GA 30084

Based on observations, staff interviews, record review and review of the facility's policies titled,

Insulin Products, the facility failed to ensure medications were properly stored by failing to remove expired medications from one of three medication rooms, and failing to properly date and discard expired insulin pens in one of five medication carts.

This deficient practice had the potential to result in residents receiving ineffective or expired medications, placing them at increased risk for adverse health outcomes.Findings include:

Review of the facility's policy titled Storage of Medications F-F761, revised 10/2024, revealed under Guidelines step 4.

The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.

All such drugs shall be returned to the dispensing pharmacy or destroyed per state regulation.

Review of the facility's reference guide by Omnicare pharmacy titled, Guidance for Using Insulin Products dated 2025 revealed Upon opening, all vials/cartridges/pens should be dated.Observation and interview on 1/28/2026 at 1:50 pm during review of the medication room A/B/E-Hall, on the second floor, with Unit Manager Registered Nurse (RN) AA, revealed 5 floor stock of 50% Dextrose injection, usp 25G/50 mL, which were located inside a box under the counter, had expired on 07/2025. RN AA confirmed the expiration of the Dextrose injections, further stating that she was not aware that it was inside that box, and immediately removed them and discarded them.

Observation and interview on 1/28/2026 at 2:15 pm during review of the B-Hall medication cart with Licensed Practical Nurse (LPN) BB revealed the following concerns: One insulin Aspart pen with an open date of 1/1/2026, and an expiration date of 1/31/2026, indicating the pen had been in use for more than 28 days and was expired as of 1/28/2026.

One Lantus Solostar insulin pen with no documented open date or expiration date; the pen was observed open and in current use.

One insulin Lispro (Humalog) KwikPen labeled with an open date of 1/28/2026 and an expiration date of 2/5/2026, reflecting a 7-day expiration rather than the manufacturer-recommended 28 days after opening.LPN BB confirmed the documented dates, or lack thereof, on the insulin pens and stated she did not open or label those pens, noting that multiple nurses utilize the medication carts as they are frequently reassigned.

She stated that once insulin is removed from refrigeration, the expiration date should be calculated as 28 days from the date opened and clearly written on the pen or vial.

She acknowledged that this process had not been followed for the identified insulin pens and stated that failure to properly date insulin could result in residents receiving ineffective medication.

The expired and undated insulin pens were discarded at the time of observation. LPN BB further stated that nurses are expected to calculate the 28-day expiration timeframe; however, she was not aware of a specific written policy outlining this requirement.

Interview on 1/30/2026 at 9:45 am with the Director of Nursing (DON) revealed that nurses are required to verify the Medication Administration Record (MAR) at least three times prior to medication administration to ensure that there are no errors before giving the medication.

The DON stated that unit managers are responsible for conducting weekly checks of medication carts and daily checks of medication rooms to ensure all medications listed on the MAR are available and properly stored.

Expired medications are to be identified and scanned back to the pharmacy promptly.

Regarding insulin management, the DON stated that all insulin maintained in medication carts must be clearly labeled with the date opened and the calculated expiration date, which is 28 days from opening.

The nurse who opens the insulin is responsible for labeling it appropriately. If an insulin vial or pen is found to be undated or expired, it must be discarded.

The DON further stated that use of expired medications may be harmful to residents and potential side effects are unknown.

115561 01/30/2026

Tucker Park Crossing of Journey LLC 4608 Lawrenceville Highway Tucker, GA 30084

Observation on 01/30/2026 at 8:19 AM revealed R18 was sitting up in bed eating breakfast and watching television.

The air filter on the back of the O2 machine was covered with fuzzy, thick, and dry gray particles.

Interview with Certified Nursing Assistant (CNA) NN on 01/27/2026 at 02:16 PM revealed that the nurses handled O2 machines.

Interview with RN CC on 01/28/2026 at 2:24 PM revealed that tubing for O2 machines was replaced on the night shift and that she was not sure how often the tubes were replaced. RN CC also stated that RT was supposed to clean filters every day and was last here Monday, 01/26/2026 and Tuesday, 01/27/2026.

Interview with Unit Manager AA on 01/30/2026 at 8:39 AM revealed she didn't know who was supposed to clean the O2 machine filters, ensure that a resident had a filter, or how often the filters were to be cleaned.

Interview with DON on 01/30/2026 at 9:28 AM revealed that the RT was supposed to follow up on all residents that were on O2.

115561 01/30/2026

Tucker Park Crossing of Journey LLC 4608 Lawrenceville Highway Tucker, GA 30084

Observation and interview on 01/28/2026 at 05:00 PM during a walk-through with the Maintenance Director revealed that all PTAC units in the building, including B, C, E, A, and D halls, required cleaning.